SCI

Stages (I-IV) of Pressure Ulcers

*Deep Tissue Injury (Suspected) Stage Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. *Stage I Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. *Stage II Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. *Stage III Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. *Stage IV Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling *Unstageable Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.

Ageing the SCI: Unique problems

*Upper-limbs for mobility *overuse of weak muscles and muscle imbalance may cause chronic shoulder pain and less often, elbow and wrist pain. *Skin changes, susceptability to pressure ulcers, decreased bone density, susceptability to bone fractures, imparied cardiovascular fitness, and renal and bowel complications *Depression *Increase in functional dependence *Decreased mobility

Incomplete Injury: Central Cord Syndrome

Central Cord Syndrome: Characterized by damage in the center of the spinal cord that results in loss of function in the arms but some leg movement. Some recovery is possible

Assessment

Check medical chart for medical clearance to begin evaluation. Also check for other trauma. Goals of initial evaluation: rapport building, teaching about their potential, learning about who they are and what is important to them. COPM

Impaiments: Acute and Chronic Pain

Chronic pain = more than half a year. Approx. 65% of people with SCI report chronic pain, especially those with tetraplegia Pain contributes to activity limitations, lack or participation, and depression

two main types of bladder dysfunction in SCI

1) neurogenic detrusor overactivity, usually associated with sphincter dysynergia (Detrusor external spincter dyssynergia: DESD) and 2) detrusor areflexia. Occasionally detrusor overactivity secondary to SCI is seen without associated sphincter dysynergia which can result in difficulty with continence.

Spinal shock

A period after the injury, characterized by areflexia (absence of reflexes) at and below the level of injury. May last hours, days, or weeks. Once spinal shock subsides, reflexes below the LOI return and become hyperactive. At the level of injury areflexia may remain as the relfex arc is interrupted

Causes of SCI

47% MVA; 23% falls or hit by object; 14% violence; 10% sports injuries; 7% non-traumatic (ex. tumor)

Bone Health

A significant decline in hip and knee region bone mineral density (BMD) occurs after motor complete spinal cord injury (SCI) which leads to a lifetime increased risk of lower extremity fragility or low trauma fracture. Preserving and maintaining bone mass is crucial to decrease the risk of fragility fractures. Within the first few days following SCI there is an increase in excreted calcium (known as hypercalciuria) that is 2-4 times that of individuals without SCI who are confined to prolonged bedrest (Bauman & Spungen 2001) and reflects excessive bone resorption. Longitudinal studies also highlight a higher rate of hypercalcemia (excessive calcium in the blood) for people after SCI that leads to rapid bone mineral loss in the first 4-6 months that slows for the remaining first year post injury (Hancock et al. 1980; Frey-Rindova et al. 2000). The immediate and excessive loss of bone mass post SCI is believed to result from a decrease in mechanical loading as a result of reduced or complete loss of muscle function and/or weight-bearing activities. Autoimmune, neural, vascular, hormonal and nutritional changes may also negatively impact bone but, the relative contributions of these factors are unknown (Jiang et al 2006).

Impairments: Autonomic dysreflexia

A sudden dangerous increase in blood pressure (more than 20-30mmHg systolic) and bradycardia (sometimes tachycardia), is a possibly life-threatening complication associated withlesions at the T6 level or above. Symptoms: hypertension, pounding headache. Common causes: distended bladder, UTI or other infection, bladder or kidney stones, fecal impaction, pressure ulcers, ingrown toenails, invasive procedures such as urinary catherterization or enema, and pain More common in tetraplegics.

Common Abbreviations Used In SCI Rehabilitation

AIS - ASIA Impairment Scale ASIA - American Spinal Injury Association (and associated International Guidelines for Neurological Classification) BI - Barthel Index (used to measure performance in activities of daily living) FIM - Functional Independence Measure (Provides a uniform system of measurement for disability based on the International Classification of Impairment, Disabilities and Handicaps; measures the level of a patient's disability and indicates how much assistance is required for the individual to carry out activities of daily living. Contains 18 items composed of: 13 motor tasks 5 cognitive tasks (considered basic activities of daily living). Tasks are rated on a 7 point ordinal scale that ranges from total assistance (or complete dependence) to complete independence. Scores range from 18 (lowest) to 126 (highest) indicating level of function. Scores are generally rated at admission and discharge. Dimensions assessed include: Eating Grooming Bathing Upper body dressing Lower body dressing Toileting Bladder management Bowel management Bed to chair transfer Toilet transfer Shower transfer Locomotion (ambulatory or wheelchair level), Stairs Cognitive comprehension Expression Social interaction Problem solving Memory LOS - Length of Stay MBI - Modified Barthel Index OT - Occupational Therapy SLT - Speech & Language Therapy PT - Physical Therapy (Physiotherapy) UTI - Urinary Tract Infection

Complete injury

Absence on sensory and motor function in the lowest sacral segment

Interventions Based on Passive Movement or Stretching: Prolonged Standing

Although it has been suggested by some that repetitive movements are deemed necessary for obtaining a clinical effect (Rosche et al. 1997), there have been several reports of reduced spasticity associated with regular periods of passive standing (Odeen & Knutsson 1981; Bohannon 1993; Kunkel et al. 1993; Dunn et al. 1998; Eng et al. 2001; Shields & Dudley-Javoroski 2005). The majority of these are individual case reports (Bohannon 1993; Kunkel et al. 1993; Shields & Dudley-Javoroski 2005) or user satisfaction surveys (Dunn et al. 1998; Eng et al. 2001) and have not been included in Table 21.1 (i.e., other than Odeen & Knutsson, 1981) which outlines the specific investigations of effectiveness of these "passive" approaches. The individuals examined in all 3 case reports reported reductions in lower limb spasticity associated with passive standing despite the fact that different procedures and devices were used across the reports including a tilt table (Bohannon 1993), a standing frame (Kunkel et al. 1993) and a stand-up wheelchair (Shields & Dudley-Javoroski 2005). In addition, a significant number of people have indicated they receive benefit with respect to reduced spasticity in response to surveys about prolonged standing programs. Specifically, Eng et al. (2001) and Dunn et al. (1998) reported that 24% and 42%, respectively, of individuals engaged in this activity find it beneficial in reducing spasticity. However, it should be noted that in each of these studies some individuals also reported an increase in spasticity with this activity (13% and 3% respectively).

Interventions Based on Passive Movement or Stretching: Hippotherapy

Another approach to spasticity reduction is hippotherapy, which involves the rhythmic movements, associated with riding a horse, to regulate muscle tone (Lechner et al. 2003; 2007). Although the specific mechanisms by which an antispastic effect may be achieved with hippotherapy is unknown, it is postulated that it may be brought about by the combination of sensorimotor stimulation, psychosomatic effects and the specific postural requirements, and passive and active movements necessary for riding a horse (Lechner et al. 2003; 2007).

Incomplete Injury: Anterior Cord Syndrome

Anterior Cord Syndrome: Characterized by damage to the front of the spinal cord, resulting in impaired temperature, touch, and pain sensations below the point of injury. Some movement can later be recovered.

HO Key Points

Anti-inflammatory medications given early post-SCI reduces development of heterotopic ossification. Warfarin may inhibit the development of heterotopic ossification post-SCI. Etidronate can halt the progression of heterotopic ossification. Pamidronate halts secondary progression of HO post surgical excision. Pulse low intensity electromagnetic field therapy is effective in preventing HO post SCI. Radiotherapy can reduce the progression of heterotopic ossification. Surgical resection of HO can improve hip range of motion. Surgical resection and pamidronate treatment halts secondary HO progression.

Incomplete Injury: Brown-Sequard Syndrome

Brown-Sequard Syndrome: Characterized by damage to one side of the spinal cord, resulting in impaired loss of movement but preserved sensation on one side of the body, and preserved movement and loss of sensation on the other side of the body.

Incomplete Injury: Cauda Equina Lesion

Cauda Equina Lesion: Characterized by injury to the nerves located between the first and second lumbar region of the spine, resulting in partial or complete loss of sensation. In some cases, nerves regrow and function is recovered.

Impairments: Respiration

Compromised breathing, especially for individuals with cervical injuries. Respiratory complications, especially pneumonia, have been identified as the leading cause of death in the first year of life after SCI. Lesions above C4, damage to the phrenic nerve results in partial of complete paralysis of the diaphragm - require ventilatory support. Lower cervical and thoracic spine injuries can result in paralysis of other breathing muscles

Impairments: Bowel and Bladder

Controlled in the S2-5 spinal segments. Therefore, all persons with complete lesions at and above this levellose their ability to void and defecate voluntarily. Safe elimination program involves both behavioural and pharmacological interventions. Bowel program for person's with paraplegia: oral meds, daily routine, managing clothing, suppository with digital stimulation (could use magnifying mirror and a lamp). To compensate for finger paralysis, the dill stick is used to stimulate the anal reflex. Bladder: Indwelling catheter, intermittent catheterization (IC), relfex voiding (males = condom and leg bag; females = diaper)

Depression

Depression is a common consequence of SCI. Depression post SCI can interfere with function and adaptation. Cognitive behavioural interventions provided in a group setting appear helpful in reducing post-SCI depression and related difficulties. The benefits of drug treatment for post-SCI depression are largely extrapolated from studies in non-SCI populations. Programs to encourage regular exercise, reduce stress, and improve or maintain health appear to have benefits in reducing reports of depressive symptoms in persons with SCI.

DESD Therapy in SCI

Due to the small capacity bladder seen with neurogenic detrusor overactivity, the potential for high bladder pressures leading to reflux, hydronephrosis, and kidney damage, and also due to the potential for incontinence, the goals of therapy are twofold: 1) to enhance bladder volume while lowering bladder filling pressures, and 2) to empty the bladder regularly in a low pressure manner, usually with intermittent catheterization in people with an intact external sphincter, or external drainage in people that have had a procedure to physically or chemically obliterate the external sphincter. * Pharmacological approaches *Electrical Stimulation to Enhance Bladder Volumes *Surgical Augmentation of the Bladder to Enhance Volume

Direct Muscle Stimulation for Reducing Spasticity

Electrical stimulation applied to individual muscles may produce a short term decrease in spasticity. There is also some concern that long-term use of electrical stimulation may increase spasticity.

Impairments: Deep vein thrombosis

Formation of a blood clot. Clot may develop further and dislodge from the venous wall, forming an embolus. Embolus may occlude pulmonary circulation. Therapist may prevent this condition by observing any asymmetry in the lower extremities in clour, size, and/or temperature.

Heterotopic Ossification (HO)

Heterotopic ossification (HO) is the formation of pathological bone in muscle or soft tissue. The incidence in individuals following a spinal cord injury (SCI) has been reported to vary greatly, ranging from 10-78% (van Kuijk et al. 2002, Banovac 2001). Banovac et al. (2001) notes HO occurs most frequently in the first 2 months after SCI below the level of paralysis. The etiology of HO is not fully understood which creates challenges in determining appropriate diagnostic and therapeutic approaches. Symptoms of heterotopic ossification appear 3-12 weeks after spinal cord injury. SCI patients typically present with joint and muscle pain, parasthesias and tissue swelling in the involved region, accompanied by mild fever (Thomas & Amstutz 1987; Orzel & Rudd 1985; Smith 1998;Shehab et al. 2002). In the initial stages of HO, clinical signs of inflammation are nonspecific (Neal 2003).

Housing and Attendent Care Key Points

In many cases, discharge from hospital is delayed for SCI patients due to lack of accessible housing, which leads to unnecessary increase of cost of care. Independent Living Centres (ILCs) that have relationships with hospital Medical Rehabilitation Programs (MRPs) serve more clients than those without, and the most frequently serviced individuals are those with SCI who attend for peer counseling, skills training, and discharge planning. Living with a spouse and/or children, living alone, or living with unrelated persons are more desirable arrangements than living with parents and spouse/children together, living with distant family (i.e., grandparents), or living with parents and siblings. Marital status, transportation barriers, education level, medical supervision requirements, economic disincentives, services received, and severity of disability are predictors of independent living. Choice and control are important when planning living situations and setting goals with clients with SCI because they are directly related to residential and life satisfaction. Individuals with SCI have lower perceived life satisfaction, locus of control, and satisfaction with certain aspects of housing than normative samples. Accommodation options for a person with a disability are limited. The preferred accommodation is a private house or apartment. Living with someone prior to SCI, having insurance or private funding for equipment, and being younger decrease the risk of being discharged to an extended care facility following SCI rehabilitation. Individuals with SCI have a need for assistance with fire safety to increase their perception of home safety. Individuals with SCI move multiple times after injury. In most cases they start living with their parents and/or in an institution before moving into their own homes. The transition process from rehabilitation setting to community is difficult because of the lack of resources mainly in terms of adaptation, accommodation and equipment. A majority of caregivers indicated to be overwhelmed with their caregiving responsibilities. Most informal caregivers are female spouses of individuals with SCI who require assistance in fulfilling and maintaining services. There is general satisfaction with informal attendant services. The most significant predictors of Personal Care Assistance (PCA) use are motor function, days spent in rehabilitation, and length of stay in a nursing home. Personal attendant turnover is positively correlated with higher injury level and increased need for assistance in exercise and transfers. Goal-directed occupational therapy can achieve gains in role performance and improvements in life satisfaction. Re-hospitalization might be reduced after participation in an educational intervention involving a workshop, a collaborative home visit, and access to follow-up. Counselling on proper technique and hygiene for at least one session might reduce the risk of urinary tract infections (UTIs) to below-threshold for individuals at risk for UTIs. Workshops for attendants and consumers can increase knowledge about SCI. Directing, training, and financing one’s personal attendant care may lead to financial savings, better health outcomes, and increased life satisfaction.

Evaluation

Spinal stability must be established prior to any physical contact with the patient. Clarify with physician how much movement and load are allowed. Upper extremity ROM, strength, muscle tone, and sensation. Patient's endurance, trunk balance, fatigability, and pain. MMT

SLOP (Sublesional osteoporosis) Detection and Diagnosis

In order to assess and understand your patient's bone health, it is important to measure their BMD and document their fracture risk. We advocate diagnosing the presence of SLOP based on the following DXA criteria (Table 3). http://www.scireproject.com/tables/bone-health-table-3-definition-of-sublesional-osteoporosis-slop We recommend documenting your patients fracture risk by completing the risk factor profile check-list (Craven et al. 2008, Craven et al. 2009). We propose that the presence of ≥3 risk factors implies a moderate fracture risk, while ≥5 risk factors implies a high fracture risk (Table 4). http://www.scireproject.com/tables/bone-health-table-4-risk-factors-lower-extremity-low-trauma-fracture-after-sci

Interventions Based on Active Movement (Including FES-assisted Movement)

In practice, active movement approaches may be conducted using a variety of exercise forms that may also provide benefits beyond spasticity reduction (e.g., strength, endurance, gait re-training). The studies meeting the criteria for the present review involve exercises performed in a therapeutic pool (i.e., hydrotherapy) (Kesiktas et al. 2004) or those associated with functional electrical stimulation (FES)-assisted cycling (Krause et al. 2008) or locomotor training programs, whether assisted by FES (Granat et al. 1993; Mirbagheri et al. 2002) or a FES-powered orthosis (Thoumie et al. 1995).

Detrusor Areflexia

In the case of a flaccid bladder, loss of detrusor muscle tone prevents bladder emptying and leads to bladder wall damage from over-filling, urine reflux and an increase in infection risk due to stasis. The sphincter tone also tends to be flaccid (at least the external sphincter) causing incontinence, especially with maneuvers that increase intraabdominal pressure (so-called "Valsalva" maneuvers) including straining during transfers, coughing and sneezing. Internal sphincter tone may be intact due to the higher origin of sympathetic innervation, thus complete emptying, even with externally applied suprapubic pressure, may be difficult. Compared to DESD, patients with detrusor areflexia comprise a much smaller proportion of the SCI population and there is very little literature examining the effectiveness of interventions for this patient subpopulation (patients with detrusor areflexia). Detrusor areflexia is seen most commonly in cauda equina lesions where the sacral reflex is disrupted. It can occasionally occur at other levels of spinal lesions. The clinical manifestation of this results in an inability for the bladder to empty completely or at all, leading to overdistension and stasis. Additionally, there is frequently incontinence due to lack of external sphincter tone, most often due to increased abdominal pressure on the bladder (i.e. stress incontinence). This can be especially problematic in persons with paraplegia that may require high valsalva forces for activities such as transferring from wheelchairs. In general, the goal is either: 1) stopping leakage and improving storage with medications and intermittent catheterization, or 2) improving emptying, either voluntarily in the incomplete injury, and/or into condom drainage in the person with more severe neurogenic bladder impairments.

C5 Tetraplegia

Individuals with C5 tetraplegia have functional use of elbow flexion. With the help of specialized assistive devices (such as wrist or hand orthotics to allow them to hold objects), these persons can achieve independence in feeding and grooming. It is important to prevent contractures of elbow flexion and forearm supination caused by unopposed biceps activity. Patients with a C5 injury can assist with upper extremity dressing and bed mobility. For persons with C5 tetraplegia, a power wheelchair with hand controls will probably be required for most of their mobility needs, although a manual wheelchair with grip enhancements (rim projections) may be used for short-distance mobility on level surfaces. Patients require assistance for most other self-care (eg, lower extremity dressing, bathing), for transfer mobility, and for bladder and/or bowel tasks. As with persons who have sustained injuries at higher cervical levels than this one, assistive technology (eg, EADLs) can play an important role in maximizing the individual's control of his/her environment, helping the patient to adjust bed height, answer phones, and use computers, lights, and televisions. Driving a specially modified or adapted van is possible

C6 Tetraplegia

Individuals with C6 tetraplegia have the added function of wrist extension. This permits tenodesis, or passive thumb adduction on the index finger during active wrist extension, which assists with grasp and release. A wrist-hand orthosis (tenodesis splint) can be used to facilitate these abilities. The patient should avoid overstretching the finger flexors, which limits the tenodesis action. C6 is the highest level at which patients can have a complete injury and still function independently without the aid of an attendant, although this situation is not common. Individuals with injuries at this level can achieve functional independence in terms of feeding, grooming, bathing, and bed mobility by using assistive devices. They can dress their upper body and assist with lower-body dressing, as well as with the bladder and bowel program. With the use of a slide board, persons with C6 tetraplegia may become independent in performing transfers from a bed to a chair, although they usually require assistance with these. Intermittent catheterization for bladder care may be possible with set-up and assistive devices, although this is not common and is technically more difficult for women than for men.[14] Manual wheelchairs with enhancement for gripping the wheel rims may be used for community mobility, although patients may prefer a power chair. Driving a vehicle with adaptations, such as a custom lift and hand controls, is an option. Patients with C6 injuries can be independent in using a phone, turning pages, and writing and typing (with assistive devices).

C7 Tetraplegia

Individuals with C7 tetraplegia have the functional ability to extend their elbow, which greatly enhances their mobility and self-care skills. C7 is usually the highest level at which patients can have an injury and still be able to live independently. They may achieve independence in feeding, upper extremity dressing, bathing, bed mobility, transfers (although they may require assistance with moving over uneven surfaces), and manual wheelchair propulsion in the community (with the exception of going over curbs). With the use of assistive devices, patients may also become independent with regard to grooming, lower extremity dressing, and bowel care. Individuals with a C7 injury, especially women, may need help with bladder care (eg, intermittent catheterization). Patients may be able to independently drive an adapted van or a car that has been adapted with hand controls. Patients with C7 tetraplegia can be independent, with or without assistive devices, in writing, typing, turning pages, answering phones, and using computers.

C8 Tetraplegia

Individuals with C8 tetraplegia have functional finger flexion, which improves their independence in terms of hand grasp and release. They can achieve independence in feeding, grooming, upper and lower extremity dressing, bathing, bed-mobility transfers, manual wheelchair propulsion, and bladder and bowel care, as well as in typing, writing, answering phones, and using computers. These persons can also drive independently using an adapted van or a car that has been adapted with hand controls.

Thoracic Paraplegia

Individuals with T1-T12 paraplegia have innervation and function of all upper extremity muscles, including those for hand function. They can achieve functional independence in self-care (including light housekeeping and meal preparation), in bladder and bowel skills, and, at the wheelchair level, in all mobility needs. Individuals should receive advanced wheelchair training so that they can move over uneven surfaces, rough terrain, and ramps and curbs, as well as do "wheelies" and make transfers from the floor to the wheelchair. Like patients with an injury to the low cervical levels, persons with thoracic paraplegia can drive independently by using an adapted van or a car adapted with hand controls. Individuals with a T2-T9 injury have variable trunk control (of the paraspinal and abdominal muscles), and they may be able to stand by using bilateral knee-ankle-foot orthoses (KAFOs) along with a walker or crutches. Persons with a T10-T12 injury have better trunk control than do patients with a higher injury, and they may be able to walk household distances independently with KAFOs and assistive devices; they may even attempt to walk up and down stairs. Unfortunately, these maneuvers can require extreme energy expenditure, and many individuals may prefer wheelchair mobility.

C1-C4 Tetraplegia (High Tetraplegia)

Individuals with complete C1-C4 (high) tetraplegia have little or no movement of upper and lower extremity muscles. They have movement of the head and neck, as well as, possibly, shoulder elevation (shrug). Persons with an injury at the C4 level have innervation of the diaphragm (the primary muscle for respiratory inspiration). They should not need long-term ventilatory assistance, although it is not uncommon to receive ventilation initially after injury. Patients with C1-C3 injuries are likely to require long-term mechanical ventilatory support because of the loss of innervation to the diaphragm. These individuals may be candidates for FES of the phrenic nerve (or diaphragm) to reduce their need for mechanical ventilation, if their lower motor innervation to the diaphragm remains intact.[10] Swallowing and phonation functions are preserved. Individuals with injuries at the C1-C4 level will likely depend on others for help with almost all of their mobility and self-care needs, although they may be able to use a power wheelchair with chin or pneumatic (sip and puff) controls. If their elbow flexion and shoulder movement are suboptimal (muscle grade 2 or 3), a balanced forearm orthosis (BFO) or mobile arm support (MAS) may assist them with feeding and grooming activities. The use of a long bottle or straw can allow these individuals to drink independently. Patients should be able to communicate with caregivers (and provide direction) about their mobility needs, as well as about self-care and bladder and/or bowel care. Assistive technologies, such as electronic aids to daily activities (EADLs, previously referred to as environmental control units), may be accessed by using a mouth stick or switch or by employing voice activation. Assistive devices transmit signals by means of radio waves, infrared light, or ultrasonographic waves to facilitate an individual's control of his/her environment. In this way, the person can accomplish such tasks as answering phones, adjusting bed height, and controlling computers, lights, and televisions. Brain Control Interface (BCI) methods, using noninvasive electroencephalography (EEG), is being trialed in order to bridge the disconnection between the brain and muscle.[11, 12] With BCI, it is necessary to interpret brain activity and interface brain signals with a computer, and this may enable a person with tetraplegia to control a computer, operate devices such as an EADL, or control a power wheelchair. Individuals using BCI systems indicate it gives them an increased sense of independence and improves their quality of life. This technology needs further refinement before it can be clinically implemented.

Nutrition Key Points

Individuals with complete tetraplegia have higher rates of altered glucose metabolism. Impaired gallbladder emptying is seen in diabetic and obese SCI individuals. A combined diet and exercise program can help patients reduce weight following SCI without compromising total lean mass and overall health. Participation in a holistic wellness program is positively associated with improved eating and weight-related behaviours in persons with SCI. A combined nutrition, exercise and behaviour modification program can help persons with SCI increase metabolically active lean tissue, work efficiency, resting oxygen uptake and strength. Dietary counseling results in improved lipid profile; consultation with a registered dietitian should be obtained, because individualized diets may enhance compliance. Blood concentrations of DHA and EPA increased as the result of n-3 fatty acid supplementation; however, no significant changes in lipid profile were identified. Omega-3 fatty acid supplementation increases upper body strength and endurance in persons with SCI. Individuals with SCI should be screened for vitamin D deficiency and, if needed, replacement therapy should be initiated. Clinicians should conduct early screening for and treatment of vitamin B12 deficiency. Creatine supplementation does not result in improvements in muscle strength, endurance or function in weak upper limb muscles. Creatine supplementation enhances exercise capacity in persons with complete tetraplegia and may promote greater exercise training benefits. Consumption of a standard liquid meal does not change blood pressure, heart rate or noradrenalin levels in tetraplegics with postural hypotension. The consumption of a whey protein plus carbohydrate supplement following fatiguing ambulation improves subsequent ambulation by increasing distance, time to fatigue and caloric expenditure in persons with incomplete SCI. Meal-induced thermogenesis is not decreased in tetraplegic individuals with low sympathoadrenal activity and efferent sympathoadrenal stimulation from the brain is not necessary for nutrient-induced thermogenesis. Impairment of sympathetic control of the kidney secondary to SCI resulting in tetraplegia does not impact renal sodium conservation in response to dietary salt restriction. More research is needed to evaluate the role of nutrition in the management of post-acute SCI to provide the evidence base required for optimal clinical decisions.

Lumbar Paraplegia

Individuals with lumbar or sacral paraplegia can achieve functional independence for all mobility, self-care, and bladder and bowel skills. Advanced wheelchair training (as mentioned above) should be undertaken. Patients with this injury can drive independently by using a car adapted with hand controls. In addition, individuals with an injury at the lumbar level can become functionally independent in terms of household and community ambulation, which is often defined as unassisted ambulation for distances of greater than 150 feet, with or without the use of braces and assistive devices. Orthotic devices (KAFOs and ankle-foot orthoses [AFOs]) are often prescribed to assist patients with lower extremity standing and walking. Full- or part-time use of a manual wheelchair is often necessary.

Depending on the level of injury, there are two distinct patterns in the clinical presentation of bowel dysfunction

Injury above the conus medullaris results in upper motor neuron (UMN) bowel syndrome and injury at the conus medullaris and cauda equine results in lower motor neuron (LMN) bowel syndrome

Bowel Management

Neurogenicbowel is a syndrome commonly observed in individuals with SCI and defined as colonic dysfunctions due to lack of central nervous control. Bowel dysfunction following spinal cord injury (SCI) is a major source of morbidity (Han et al. 1998; Stone et al. 1990a). The level and severity of SCI are important factors to consider when deciding on bowel management strategies with the goal of re-establishing some level of evacuation control. Clinical experience indicates that a successful bowel program results in predictable, regular and thorough evacuation of the bowels without the occurrence of incontinence and additional complications (i.e. autonomic dysreflexia). An effective bowel program takes into consideration diet and nutritional factors, use of medications when necessary and is consistent with the neurologic condition and needs of the individual with SCI.It is important to emphasize that each person with SCI is unique and that individual bowel programs need to be client-specific.

Urinary Tract Infections: Non-Pharmacological Methods of Preventing UTIs

Intermittent Catheterization NS Prevention of UTIs •Sterile and clean approaches to intermittent catheterization seem equally effective in minimizing UTIs in inpatient rehabilitation. •Similar rates of UTI may be seen with intermittent catheterization as conducted by the patients themselves or by a specialized team during inpatient rehabilitation. •Similar rates of UTI may be seen with intermittent catheterization, whether conducted in the short-term during inpatient rehabilitation or in the long-term while living in the community. •UTIs were not associated with differences in residual urine volumes after intermittent catheterization. Intermittent Catheterization using Specially Coated Catheters for Preventing UTIs •A reduced incidence of UTIs or reduced antibiotic treatment of symptomatic UTIs have been associated with pre-lubricated or hydrophilic catheters as compared to standard non-hydrophilic catheters. Other Issues Associated with Bladder Management and UTI Prevention •Intermittent catheterization is associated with a lower rate of UTI as compared to use of indwelling or suprapubic catheter. •The Statlock device to secure indwelling and suprapubic catheters may lead to a lower rate of UTI. •Removal of external condom drainage collection systems at night or for 24 hours/day may reduce perineal, urethral or rectal bacterial levels but has no effect on bacteriuria. •The presence of vesicoureteral reflux likely has a greater impact on development of significant infections than the choice of bladder management.

UMN bowel syndrome, or hyperreflexic bowel

Is characterized by increased colonic wall and anal tones. Voluntary (cortical) control of the external anal sphincter is disrupted and the sphincter remains tight, thereby promoting retention of stool. The nerve connections between the spinal cord and the colon, however, remain intact; therefore, there is preserved reflex coordination and stool propulsion. The UMN bowel syndrome is typically associated with constipation and fecal retention at least in part due to external anal sphincter activity (Steins et al. 1997). Stool evacuation in these individuals occurs by means of reflex activity caused by a stimulus introduced into the rectum, such as an irritant suppository or digital stimulation.

LMN bowel syndrome, or areflexic bowel

Is characterized by the loss of centrally-mediated (spinal cord) peristalsis and slow stool propulsion. A segmental colonic peristalsis occurs only due to the activity of the intrinsic myenteric plexus, resulting in the production of drier and round- shaped stool. LMN bowel syndrome is commonly associated with constipation and a significant risk of incontinence due to the atonic external anal sphincter and lack of control over the levator ani muscle that causes the lumen of the rectum to open.

Neurological level

Is the lowest level at which key muscles grade 3 or above out of 5 on manual muscle testing and sensation is intact for this level's dermatome. Also the level above must have normal strenght and sensation. It is determined by testing 28 key points on each side of the body

Zone of partial preservation

Is used for patients with complete injuries who have partial innervation in dermatomes below the neurological level

Impairments: Mechanical pain

Local soft tissue pain associated with the injury. Mechanicial pain, common in the shoulder of the person with tetraplegia, may be caused by direct trauma, muscle imbalance, and overuse of weak muscles. It is the most common

Tetraplegia

Loss or impairment in motor and/or sensory function in the cervical segments of the spinal cord resulting in functional impariment in the arms, trunks, legs, and pelvic organs

Paraplegia

Loss or impairment in motor and/or sensory function in the thoracic, lumbar, or sacral segments of the cord resulting in impairment in the trunk, legs, and pelvic organs and sparing of the arms

Impairments: Termperature regulation

Many people with SCI cannot regulate body temperature, which can lead to hypothermia and heat stroke. Education is important

The return of motor and sensory abilitlies

Most motor and sensory return, both in complete and incomplete injuries, occurs in the first 6 months post onset; the rate of recovery is minimal after a year

Direct Spinal Cord and Transcranial Magnetic Stimulation

Spinal cord stimulation may provide spasticity relief over a few months but long-term effectiveness and cost-effectiveness is less certain. Repetitive transcranial magnetic stimulation may provide spasticity relief over the short-term but long-term effectiveness is unknown.

Upper Limb Key Points

Neuromuscular stimulation-assisted exercise following a spinal cord injury is effective in improving muscle strength, preventing injury and increasing independence in all phases of rehabilitation. Augmented feedback does not improve motor function of the upper extremity in SCI rehabilitation patients. Intrathecal baclofen may be an effective intervention for upper extremity hypertonia of spinal cord origin. Afferent inputs in the form of sensory stimulation associated with repetitive movement and peripheral nerve stimulation may induce beneficial cortical neuroplasticity. Restorative therapy interventions need to be associated with meaningful change in functional motor performance and incorporate technology that is available in the clinic and at home. The use of concomitant auricular and electrical acupuncture therapies when implemented early in acute spinal cord injured persons may contribute to neurologic and functional recoveries in spinal cord injured individuals with AIS A and B. There is clinical and intuitive support for the use of splinting for the prevention of joint problems and promotion of function for the tetraplegic hand; however, there is very little research evidence to validate its overall effectiveness. Shoulder exercise and stretching protocol reduces post SCI shoulder pain intensity. Acupuncture and Trager therapy may reduce post-SCI upper limb pain. Prevention of upper limb injury and subsequent pain is critical. Reconstructive surgery appears to improve pinch, grip and elbow extension functions that improve both ADL performance and quality of life in tetraplegia. The use of neuroprostheses appears to have a positive impact on pinch and grip strength and ADL functions in C5-C6 complete tetraplegia; however, access to the devices is limited and they continue to be expensive. The IST-12 neuroprosthesis, a second generation, myoelectrically controlled implantable device appears to have a positive effect on pinch and grasp functions which result in increased independence with activities of daily living.

Work and Employment: Key Points

Non-modifiable personal characteristics such as being male and Caucasian, younger at injury, with a longer duration of injury (20-30 years) with a higher pre-injury education, less severely injured, and being employed at injury in a low-intensity job increase the likelihood of employment post-SCI. Modifiable personal characteristics such as being married, highly educated, limiting the occurrence of health complications with a higher level of independence (including wheelchair skills), valuing work increase the likelihood of employment post-SCI. Environmental barriers to employment are social or physical and include financial disincentives, discrimination associated with negative attitudes toward people with disabilities and difficulties with physical access to workplace. Environmental facilitators include having access to various assistive devices, using transportation independently and having the possibilities of work adaptation including reduced work hours. A single environmental factor can be perceived either as a barrier or a facilitator to employment based on its presence/absence in one’s environment and its impact on effective returning to work. People with SCI may benefit from vocational rehabilitation in the process of job placement and work reintegration. There is a dearth of high quality research in vocational (re) training. Consequently, conclusions are based on evidence from observational studies or case studies. Continuous support to the employee and employer before and after vocational placement might lead to a successful return to work and job retention.

Evaluation: Hand

Observe hand while the person is performing activities such as picking up coins or pieces of a game or eating

Interventions Based on Passive Movement or Stretching: Neurodevelopmental therapy (NDT)

One class of therapies employed by physiotherapists and occupational therapists which utilize passive (and active) movement and stretching represent those developed mostly for stroke rehabilitation such as Bobath (neurodevelopmental) therapy and proprioceptive neuromuscular facilitation or other approaches such as those advocated by Rood or Brunnstrom. Although normalization of movement (sometimes associated with spasticity reduction) is at the basis of most of these approaches, it is noted that advocates for Bobath define this approach as more of a continually evolving, problem-solving concept that forms a framework for specific clinical practice (Raine, 2007). Anecdotally, these approaches appear to be in widespread practice although there are no reports that document the extent of their actual use in clinical practice within SCI rehabilitation. Li et al. (2007) recently conducted an RCT involving the use of 3 of these approaches (Bobath, Rood, Brunnstrom) in combination with Baclofen therapy to reduce spasticity.

Various Forms of Afferent Stimulation for Reducing Spasticity

Ongoing transcutaneous electrical nerve stimulation (TENS) programs result in short-term reductions in spasticity which may last for up to 24 hours. Penile vibration and rectal probe stimulation may be effective at reducing lower limb muscle spasticity for several hours. Other forms of afferent stimulation including massage, cryotherapy, helium-neon irradiation, and whole-body vibration may result in immediate spasticity reduction but require more research to examine long-term effects.

Lower Limb Key Points

PES programs are beneficial in preventing and restoring lower limb muscle atrophy as well as improving lower limb muscle strength and endurance. FES-assisted exercise programs are beneficial in preventing and restoring lower limb muscle atrophy as well as improving lower limb muscle strength and endurance in motor complete SCI. For patients less than 12 months post-SCI, body weight supported treadmill training has equivalent effects on gait outcomes to conventional rehabilitation consisting of overground mobility practice. Body weight-support gait training strategies can improve gait outcomes in chronic, incomplete SCI, but no body weight-support strategy (overground, treadmill, with FES) is more effective. There is limited evidence for the benefits of combining the use of certain pharmacological agents with gait training on ambulation in individuals with SCI. FES-assisted walking can enable walking or enhance walking speed in incomplete SCI or complete (T4-T11) SCI. Regular use of FES in gait training or activities of daily living can lead to improvement in walking even when the stimulator is not in use. There is limited evidence that bracing alone does not enable significant gains in functional ambulation for people with complete SCI. The advantages of bracing appear largely restricted to the general health and well-being benefits related to practice of standing and the ability to ambulate short-distances in the home or indoor settings. The benefits of bracing-alone on functional ambulation are primarily with people with incomplete spinal lesions. There is limited evidence that a combined approach of bracing and FES results in additional benefit to functional ambulation in paraplegic patients with complete SCI. Locomotor training programs are beneficial in improving lower limb muscle strength although in acute SCI similar strength increases may be obtained with conventional rehabilitation. The real benefit of locomotor training on muscle strength may be realized when it is combined with conventional therapy. This should be further explored in acute, incomplete SCI where better functional outcomes may be realized with the combination of therapies.

Impaiments: Radicular pain/segmental root pain

Pain that often follows the segmental distribution of the nerve.

Impaiments: Neuropathic pain/differntation or central pain)

Pain that originates in the SC and is thought to be the result of misdirected neural sprouting after the injury.

Incomplete injury

Partial preservation of sensory and/or motor function below the neurological level and including the lowest sacral segment

Interventions Based on Passive Movement or Stretching: Passive stretching

Passive movement may be accomplished by therapist/care-giver or self-mediated limb movement focusing on muscle stretching or on preserving full range of motion over joints that may be immobilized (Harvey et al. 2009). Alternatively, a mechanical device may be employed such as a motorized therapy table (Skold 2000) or exercise cycle (Kakebeeke et al. 2005; Kiser et al. 2005; Rayegan et al. 2011). These mechanical devices have the advantages for research purposes of producing repeatable movements over a specific range and also in standardizing other parameters (e.g., frequency, speed). They are however, commonly not accessible for routine clinical use and may present an obstacle for multicentre trials.

Tenodesis grasp

Passive opening of the fingers when the wrist is flexed and closing of the fingers when the wrist is extended

Impariment: Heterotopic occification

Pathological bone formation in joints. Connective tissue calicifies around the joint. Usually appears 1-4 months after injury Symptoms: warm, swollen extremity, fever, and/or ROM limitations. Often seen in hip/shoulder. Can result in joint contractures. Therapy: Positioning, ROM

Impairment: Fatigue

Persistent pain, antispasmodic medications, and prolonged bed rest are physical factors that can make the patient feel tired or sleepy. Compounded by restless nights interrupted by hospital routines (repositioning, cheching vital signs, admin meds)

Syringomyelia

Post-traumatic syringomyelia is a term used to describe the formation of an intramedullary cyst filled with cerebrospinal fluid (CSF) within the spinal cord (Brodbelt & Stoodley, 2003). Though uncommon, its impact can be devastating following spinal cord injury (SCI). It can be seen as early as two months after injury, or may occur years later. The classical symptoms of syringomyelia with suspended sensory loss, segmental weakness and burning are often not present in SCI patients. Many individuals may lack symptoms in general or present with nonspecific symptoms that may be attributed to other complications of spinal cord injury such as spasticity, autonomic dysreflexia or neuropathic pain. Most common symptoms include radicular pain, gait ataxia, sensory disturbance, dysesthesias and motor weakness (Brodbelt & Stoodley, 2003; Klekamp & Samii, 2002; Lyons, Brown, Calvert, Woodward, & Wriedt, 1987; Kramer & Levine, 1997). As syringomyelia progresses, reduction in sensation and increased spasticity may be seen (Carroll & Brackenridge, 2005). Progression is usually slow in most patients, with the clinical picture remaining static for many years (Mariani et al., 1991).

Incomplete Injury: Posterior Cord Syndrome

Posterior Cord Syndrome: Characterized by damage to the back of the spinal cord, resulting in good muscle power, pain, and temperature sensation, but poor coordination

Braden scale

Pressure ulcer risk assessment scale. Seemed to be the best tool available currently, as it is well validated.

Psychological Adaptation

Reactions to SCI may include: periods of shock, anxiety, denial, depression, internalized and externalized anger, adjustment, and acknowledgment.

Skeletal level

Refers to the level of greatest vertebral damage

Description of SCI Rehabilitation Outcomes

Rehabilitation Length of Stay •Those with higher level and more severe injuries have longer rehabilitation LOS. •Rehabilitation LOS in the US and Israel has become progressively shorter over the last few decades. Neurological and Functional Status •Most individuals make significant functional gains during inpatient rehabilitation. •A significant proportion of people improve 1 AIS (ASIA Impairment Scale) grade in the first few months post-injury particularly those initially assessed AIS B and C.

Pressure Ulcers Risk Factors

Risk factors that have been identified most often include: limitation in activity and mobility, injury completeness, moisture from bowel and bladder incontinence, lack of sensation, muscle atrophy, poor nutritional status and being underweight. Studies have also found that those most likely to develop pressure ulcers are male, have lower levels of education, are unemployed and do not practice standing. Other risk factorsinclude: smoking, number of comorbidities especially renal, cardiovascular, pulmonary disease and diabetes; residing in a nursing home/hospital; autonomic dysreflexia, anemia and hypoalbuminemia; spasticity and a history of previous ulcers; and an increase in tissue temperature; race and ethnicity.

Impairment: Spasticity and Spasms

SCI often results in an increase in transmission within the synaptic stretch reflex, resulting in spasticity. Spasicity develops into clonic or tonic spasms triggered by sensory stimuli such as sudden touch, infection, or other irritation.

Pyschological considerations into evaluation and treatment

Set aside preconceived biases. Concentrate on learning to know patients Provide psychological support Select activities with a just right challenge When providing information don't overwhelm person with to much detail Accept patients emotional states without judging them

Spasticity: Determining Impact of Treatment

Sometimes, increased spasticity is beneficial for transfers and mobility, and the reduction of tone may negatively impact those activities of daily living. The goal should not be to modify the excitability and rigorousness of reflexes, but to overcome functional impairments related to "spasticity" (Dietz 2000). Therefore, the decision to treat "spasticity" should not only be based on the findings gained by the examination in passive (lying bed, sitting in the wheelchair) but also in active conditions (like walking, doing transfer etc.). As well, spasticity can be protective against skeletal muscle atrophy that in turn could indirectly affect functional independence, ambulation and incidence of fracture (Gorgey & Dudley 2008). Spasticity has also been reported to increase glucose uptake and thereby reduce the risk of diabetes in SCI (Bennegard & Karlsson 2008). Furthermore, recent reports identifying spasticity related enhancement/detraction of sexual activity in males/females respectively (Anderson et al. 2007a&b), again exemplifies the importance of individualized treatment choices.

Impariments: Orthostatic hypotension, or postural hypotension

Sudden drop in blood pressure occuring when a person assumes an upright position. Most common in patients with lesions at T6 level and above. Caused by impaired autonomic regulation. Have the patient move slowly and in stages and letting the blood pressure adjust to the change. Elevating HOB, using a tilt table, or reclining wheelchair can accomplish this. Also patient may benefit from abdominal binders and elastic stockings.

Functional level

Term used by OT's, refers to the lowest segment at which strength of key muscles is graded 3+ or above out of 5 on MMT and sensation in intact. Key muscles are those that significantly change functional outcomes

ASIA Impairment Scale

The ASIA Impairment Scale classifies the completeness of SCI on a scale from A-E, as follows: A = Complete: No motor or sensory function is preserved in the sacral segments S4-S5. B = Incomplete: Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5. C = Incomplete: Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3. D = Incomplete: Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more. E = Normal: motor and sensory function are normal

Neurologic level of injury (NLOI)

The NLOI is defined as the most caudal (ie, lowest) level of the spinal cord that has normal motor and sensory function. The motor level, which is a better predictor of the patient's functional abilities, is determined by the manual testing of key muscle groups on both sides of the body. These groups represent neurologic levels, and findings are graded 0-5.

Dermatome

The area of skin innervated by the sensory axons within each segmental nerve (root)

Pathophysiology of Heterotopic Ossification

The mechanism underlying heterotopic ossification following spinal cord injury is not fully understood but it appears to be initiated by mesenchymal cells into bone precursor cells (Schuetz et al. 2005). Pape et al. (2004) has noted that mesenchymal stem cells can differentiate into osteogenic cells given the right stimuli within the right environment, even soft tissues (Chalmers et al. 1975). These mesenchymal stem cells can generate cartilage, bone, muscles, tendons, ligaments or fat (Williams et al. 1999) and are thought to play a pivotal role in the development of HO (Pape et al. 2004). HO then forms through a typical process beginning with the formation of a protein mixture created by bone cells (osteoid) that eventually calcifies within a matter of weeks (Pape et al. 2001). Over the next few months, the calcified osteoid remodels and matures into well-organized trabecular bone (Pape et al. 2001). Months following the initial trauma patients develop bone formation in muscle and soft tissues adjacent to a joint (paraarticular) with resultant restriction in range of motion, pain and ankylosis (Banovac & Gonzalez 1997, Garland et al. 1980). The bony lesion has a high metabolic rate, adding new bone at more than three times the rate of normal bone. Osteoclastic (bone removal cell) density is more than twice that found in healthy bone (Puzas et al. 1987). It is suspected there may be a neurogenic factor contributing to HO but the mechanism is poorly understood (Hurvitz et al. 1992, Pape et al. 2001, Pape et al. 2004).

The Risk for Cardiovascular Disease in Persons with SCI

The role of arteriosclerosis (i.e., narrowing and hardening of the arteries) on the development of CVD is clear (Grey et al 2003). Persons with SCI appear to be particularly susceptible to the development of arteriosclerosis (Bravo et al 2004). Researchers have revealed that persons with SCI exhibit a series of risk factors for arteriosclerosis and thus CVD

Cardiovascular Health: Key Points

There is growing evidence that Body Weight Supported Treadmill Training (BWSTT) can improve indicators of cardiovascular health in individuals with complete and incomplete tetraplegia and paraplegia. Tetraplegics and paraplegics can improve their cardiovascular fitness and physical work capacity through aerobic arm cycling exercise training which are of moderate intensity, performed 20-60 min day, at least three times per week for a minimum of six to eight weeks. Resistance training at a moderate intensity at least two days per week also appears to be appropriate for the rehabilitation of persons with SCI. It remains to be determined the optimal exercise intervention for improving cardiovascular fitness. Interventions that involve Functional Electrical Stimulation (FES) training a minimum of 3 days per week for 2 months may improve muscular endurance, oxidative metabolism, exercise tolerance, and cardiovascular fitness. Aerobic and FES exercise training may lead to clinically significant improvements in glucose homeostasis in persons with SCI. Preliminary evidence indicates that a minimum of 30 min of moderate intensity training on 3 days per week is required to achieve and/or maintain the benefits from exercise training. Aerobic and FES exercise training may lead to improvements in lipid lipoprotein profile that are clinically relevant for the at risk SCI population. The optimal training program for changes in lipid lipoprotein profile remains to be determined. However, a minimal aerobic exercise intensity of 70% of heart rate reserve on most days of the week appears to be a good general recommendation for improving lipid lipoprotein profile in persons with SCI.

Detrusor Overactivity Associated with Sphincter Dysynergia (DESD)

This type of dysfunction tends to be seen in those with injuries of the spinal cord affecting the upper motor neurons. In these cases, the lack of coordination of the sphincter and the detrusor is caused by lack of coordination from the pontine micuturition centre due to the spinal cord injury. Both the detrusor and the sphincter are overactive due to lack of control and descending inhibition from the pons and cortex, and both sphincter and detrusor contract reflexively when stretched. The detrusor becomes overactive, reflexively contracting at small volumes against an overactive sphincter, resulting in high bladder pressures. This leads to incontinence (when the detrusor contracts hard enough to overcome the sphincter contraction), incomplete emptying (due to sphincter co-contraction), and reflux (due to high bladder pressures) with resultant recurrent bladder infections, stones, hydronephrosis, pyelonephritis, and renal failure.

Defining Urinary Tract Infections

Urinary tract infections (UTIs) are a common secondary health condition following SCI and a major cause of morbidity These designate a UTI as indicative of significant bacteriuria with tissue invasion and resultant tissue response with some or all of the following signs and / or symptoms: •Leukocytes in the urine generated by the mucosal lining, •Discomfort or pain over the kidneys or bladder, or during urination, •Onset of urinary incontinence, •Fever, •Increased spasticity, •Autonomic hyperreflexia, •Cloudy urine with increased odor, •Malaise, lethargy, or sense of unease.

Impaiments: Sexual function

Usually male patients with complete injuries are unable to have psychronic (voluntary) erections and ejaculations. They can, however, have reflex erections that may be controlled by stimulation, such as pulling the pubic hairs. Complete injuries at S2-5 lose bowel, bladder, and genital reflexes and have a complete loss of erection. Male fertility is decreased after SCI. Advances in technology, however, provide ways for males to sustain an erection and improve the chance of fathering a child. Women: sexual and reproductive functioning is less affected in women. However, consequences related to these issues are disreflexia and bladder incontinence during intercourse and complications of pregnancy and delivery

Setting goals: Questions to answer

What must be done to prevent further deformities and complications? What activity is important to the patient to engage in right now Adolescent: *Reentering the student role *Sexual roles *Driver role *They are minors - therefore, parental participation and consent

Descending tracts

carry information from the brain downwards to initiate movement and control body functions

Ascending tracts

carry sensory information from the body, upwards to the brain, such as touch, skin temperature, pain and joint position.

Spasticity

disordered sensori-motor control, resulting from an upper motor neuron lesion, presenting as intermittent or sustained involuntary activation of muscle

A diagnosis of Major Depressive Disorder

in an adult requires at least a two-week period of five or more symptoms, with at least one either depressed mood or a loss of interest or pleasure in almost all activities. Further symptoms may include: •Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. •Insomnia (inability to sleep) or hypersomnia (sleeping too much) nearly every day. •Psychomotor agitation or retardation nearly every day. •Fatigue or loss of energy nearly every day. •Feelings of worthlessness or excessive or inappropriate guilt nearly every day. •Diminished ability to think or concentrate, or indecisiveness, nearly every day. •Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Physical Activity and Periodic Leg Movements

•Aerobic exercise is effective in reducing night-time periodic limb movements in persons with complete paraplegia.

Effectiveness of Interventions to Increase Physical Activity Participation in SCI

•Behavioural interventions promoting physical activity in the SCI population can lead to increased levels of physical activity participation.

Gait Retraining Strategies to Enhance Functional Ambulation

•Body-weight Supported Treadmill Training (BWSTT) •Special Case Reports: Spinal Cord Stimulation Combined with BWSTT •Combined Gait Training and Pharmacological Interventions •Special Case Report: Nutrient Supplement to Augment Walking Distance •Functional Electrical Stimulation (FES) •Orthoses/Braces •Whole-Body Vibration for Gait Rehabilitation •Enhancing Strength Following Locomotor Training in Incomplete SCI •Cellular Transplantation Therapies to Augment Strength and Walking Function

Urinary Tract Infections: Detecting and Investigating UTIs

•Both limited and full microbial investigation may result in adequate clinical response to UTI treatment with antibiotics. •Indwelling or suprapubic catheters should be changed just prior to urine collection so as to limit the amount of false positive urine tests. •Urinalysis and urine culture results of SCI patients are not likely to be affected by sample •refrigeration (up to 24 hours). •It is uncertain if dipstick testing for nitrates or leukocyte esterase is useful in screening for bacteriuria to assist treatment decision-making.

Sensory function is determined by examining 28 key sensory points on both sides of the body. These points are designated within dermatomes for light touch and pin prick. They are graded as follows: 2 = normal, 1 = impaired, and 0 = absent. Sensory levels are designated as follows:

•C2 - Occipital protuberance •C3 - Supraclavicular fossa •C4 - Top of acromioclavicular joint •C5 - Lateral antecubital fossa •C6 - Thumb •C7 - Middle finger •C8 - Little finger •T1 - Medial antecubital fossa •T2 - Apex of axilla •T3 - Third intercostal space (IS) •T4 - Fourth IS (nipple line) •T5 - Fifth IS (midway T4-T6) •T6 - Sixth IS (xiphisternum) •T7 - Seventh IS (midway T6-T8) •T8 - Eighth IS (midway T6-T10) •T9 - Ninth IS (midway T8-T10) •T10 - Tenth IS (umbilicus) •T11 - 11th IS (midway T10-T12) •T12 - Inguinal ligament (midpoint) •L1 - Half the distance T12-L2 •L2 - Midanterior thigh •L3 - Medial femoral condyle •L4 - Medial malleolus •L5 - Dorsum of foot (third metatarsophalangeal joint) •S1 - Lateral heel •S2 - Popliteal fossa (midline) •S3 - Ischial tuberosity •S4-5 - Perianal area

Motor levels representing upper and lower extremity function (and key muscles) are as follows:

•C5 - Elbow flexion (biceps) •C6 - Wrist extension (extensor carpi radialis) •C7 - Elbow extension (triceps) •C8 - Finger flexion (flexor digitorum profundus) •T1 - Small finger abductors (abductor digiti minimi) •L2 - Hip flexion (iliopsoas) •L3 - Knee extension (quadriceps) •L4 - Ankle dorsiflexion (tibialis anterior) •L5 - Great toe extension (extensor hallucis longus) •S1 - Ankle plantar flexion (gastrocsoleus complex)

DESD Therapy in SCI: Other Miscellaneous Treatments

•Early electroacupuncture therapy as adjunctive therapy may result in decreased time to achieve desired outcomes. •Intranasal DDVAP may reduce nocturnal urine emissions and decrease the frequency of voids (or catheterizations). •Anastomosis of the T11, L5 or S1 to the S2-S3 spinal nerve roots may result in improved bladder function in chronic SCI.

Physical Activity and Subjective Well-Being

•Exercise is an effective strategy for improving at least two aspects of subjective well-being - depression and quality of life.

Non-pharmacologic Therapy for Prevention and/or Treatment of Bone Health

•FES-cycling does not improve or maintain bone at the tibial midshaft in the acute phase but may increase/maintain lower extremity BMD the longer time since injury. •Electrical stimulation can maintain or increase BMD over the stimulated areas. •There is inconclusive evidence for Reciprocating Gait Orthosis, long leg braces, passive standing or self-reported physical activity as a treatment for low bone mass. •There is a lack of definitive evidence supporting non-pharmacological interventions for either prevention or treatment of bone loss after a SCI.

Physical Activity and Respiratory Complications

•For exercise training to improve respiratory function the training intensity must be relatively high (70-80% of maximum heart rate) performed three times per week for six weeks. Ideal training regimes have not been identified. •There is limited evidence that inspiratory muscle training improves respiratory muscle strength or endurance in people with SCI.

MMT Grades

•Grade 5 - Normal; muscle movement through the complete range of motion (ROM) against gravity and full resistance •Grade 4 - Good; muscle movement through the complete ROM against gravity and moderate resistance •Grade 3 - Fair; muscle movement through the full ROM against gravity alone •Grade 2 - Poor; muscle movement through the full ROM with gravity eliminated •Grade 1 (Trace) - Palpable muscle contraction or joint movement, but not through complete ROM, even with gravity eliminated •Grade 0 - Zero; no muscle movement or palpable contraction

Physical Activity and Spasticity

•Hippotherapy may result in short-term reductions in spasticity. •A combination of neural facilitation techniques and Baclofen may reduce spasticity. •Rhythmic passive movements may produce short-term reductions in spasticity. •Prolonged standing or other methods of producing muscle stretch may result in reduced spasticity. •Active exercise interventions such as hydrotherapy and (FES) functional electrical stimulation-assisted walking may produce short-term reductions in spasticity.

Effect of Intensity on Rehabilitation Outcomes

•Increased therapeutic intensity may not necessarily lead to functional benefits, but data is scarce.

Barriers to Physical Activity Participation in the SCI Population

•Individuals with SCI encounter numerous impediments to physical activity participation including intrapersonal, systemic, and expertise barriers. Interventions are needed to help people with SCI manage these barriers

Differences in Traumatic vs Non-Traumatic SCI Rehabilitation Outcomes

•Individuals with nontraumatic SCI have reduced LOS and less functional improvement with rehabilitation as compared to those with traumatic SCI, although additional studies that better control for nontraumatic subtypes are required.

Comparing Methods of Conservative Bladder Emptying

•Intermittent catheterization, whether performed acutely or chronically, has the lowest complication rate. •Indwelling catheterization, whether suprapubic or urethral or whether conducted acutely or chronically, may result in a higher long-term rate of urological and renal complications than other management methods. •Persons with tetraplegia and complete injuries, and to a lesser degree females, may have difficulty in maintaining compliance with intermittent catheterization procedures following discharge from rehabilitation. •Intermediate Catheterization •Although both pre-lubricated and hydrophilic catheters have been associated with reduced incidence of UTIs as compared to conventional Poly Vinyl Chloride catheters, less urethral microtrauma with their use may only be seen with pre-lubricated catheters. •Urethral complications and epididymoorchitis occur more frequently in those using intermittent catheterization programs. •Portable ultrasound device can improve the scheduling of intermittent catheterizations

Bone Health & Fracture

•Low trauma fractures, especially around the knee, are common in people with SCI. •Bone health management should begin early following SCI as there is a significant decline in lower extremity BMD in the first year and the efficacy of drug interventions appear to be most effective with a shorter time period between injury onset and drug administration •Measurement and monitoring of hip and knee region BMD after SCI are essential to identify low bone mass and quantify lower extremity fracture risk.

Effect of Gender and Race on Rehabilitation Outcomes

•Neither gender nor race effects have been demonstrated for discharge destination, rehabilitation LOS and neurological or functional status in US Model Systems data

Condom Catheterization

•Patients using condom drainage should be monitored for complete emptying and for low pressure drainage, to reduce UTI and upper tract deterioration. Sphincterotomy may eventually be required. •Penile implants may allow easier use of condom catheters and reduce incontinence. •Continent Catheterizable Stoma and Incontinent Urinary Diversion •Catheterizable abdominal stomas may increase the likelihood of achieving continence and independence in self-catherization, and may result in a bladder management program that offers more optimal upper tract protection. •Cutaneous ileal conduit diversion may increase the likelihood of achieving continence but may also be associated with a high incidence of various long-term complications.

Physical Activity and Functional Improvement Including Activities of Daily Living

•Physical activity programming may be useful in improving functional outcomes such as performance of ADLs but there is very little information describing specific exercise parameters that would be most effective in this respect.

Physical Activity and Pain

•Regular exercise reduces post-SCI pain. •Shoulder exercise protocol reduces post-SCI shoulder pain intensity

Electrical Stimulation for Bladder Emptying (and Enhancing Volumes)

•Sacral anterior root stimulation (accompanied in most cases by posterior sacral rhizotomy) enhances bladder function and is an effective bladder management technique though the program (surgery and followup) requires significant expertise. •Direct bladder stimulation may be effective in reducing incontinence and increasing bladder capacity but requires further study. •Posterior sacral, pudenal,dorsal penile or clitoral nerve stimulation may be effective to increase bladder capacity but requires further study. •Early sacral neural modulation may improve management of lower urinary tract dysfunction but requires further study.

Physical Activity and Bone Health

•Short term (6 weeks) therapeutic ultrasound is not effective for preventing bone loss after SCI. •FES-cycling does not improve or maintain bone at the tibial midshaft in the acute phase but may increase/maintain lower extremity BMD the longer time since injury. •Electrical stimulation can maintain or increase BMD over the stimulated areas. •Six months of FES cycle ergometry may increase lower extremity BMD over areas stimulated. •There is inconclusive evidence for Reciprocating Gait Orthosis, long leg braces, passive standing or self-reported physical activity as a treatment for low bone mass

Sphincterotomy, Artificial Sphincter, Stents and Related Approaches for Bladder Emptying

•Surgical and prosthetic approaches (with a sphincterotomy and stent respectively) to allow bladder emptying through a previously dysfunctional external sphincter both seem equally effective resulting in enhanced drainage although both may result in long-term upper and lower urinary tract complications. •Artificial urinary sphincter implantation and transurethral balloon dilation of the external sphincter may be associated with improved bladder outcomes but require further study.

Physical Activity and Secondary Conditions

•There is limited evidence that BWSTT can improve indicators of cardiovascular health in individuals with complete and incomplete SCI. •Tetraplegics and paraplegics can improve their cardiovascular fitness and physical work capacity through aerobic exercise training of moderate intensity, performed 20-60 min day, at least three times per week for a minimum of six to eight weeks. Resistance training at a moderate intensity at least two days per week also appears to be appropriate for the rehabilitation of persons with SCI. It remains to be determined the optimal exercise intervention for improving cardiovascular fitness. •Interventions that involve FES training a minimum of 3 days per week for 2 months can improve muscular endurance, oxidative metabolism, exercise tolerance, and cardiovascular fitness. •Aerobic and FES exercise training may lead to clinically significant improvements in glucose homeostasis in persons with SCI. Preliminary evidence indicates that a minimum of 30 min of moderate intensity training on 3 days per week is required to achieve and/or maintain the benefits from exercise training. •Aerobic and FES exercise training may lead to improvements in lipid lipoprotein profile that are clinically relevant for the at risk SCI population. The optimal training program for changes in lipid lipoprotein profile remains to be determined. However, a minimal aerobic exercise intensity of 70% of heart rate reserve on most days of the week appears to be a good general recommendation for improving lipid lipoprotein profile in persons with SCI.

Physical Activity Participation Levels in SCI

•There is tremendous variability in the amount of physical activity performed by people living with SCI. A large segment of the population does not engage in any leisure-time physical activity whatsoever.

Triggering-Type of Expression Voiding Methods of Bladder Management

•Valsalva or Crede maneuver may assist some individuals to void spontaneously but produce high intra-vesical pressure, increasing the risk for long-term complications.

Physical Activity: Effects on Muscle Morphology, Strength and Endurance in Persons with SCI

•Various forms of exercise, most notably functional electrical stimulation of upper and lower limbs, body-weight support treadmill training and circuit resistance training, may be effective in increasing muscle strength and reducing muscle atrophy. The former two are more appropriate for those with greater muscle impairment.

Indwelling Catheterization (Indwelling or Suprapubic)

•With diligent care and ongoing medical follow-up, indwelling suprapubic catheterization may be an effective and satisfactory bladder management choice for some people, though there is insufficient evidence to report lifelong safety of such a regimen •Indwelling catheter users are at higher risk of bladder cancer, especially in the second decade of use, though risk also increases during the first decade of use.

Effect of Age on Rehabilitation Outcomes

•Younger individuals with paraplegia are more likely to have shorter rehabilitation LOS than older individuals. •Younger individuals are more likely to make greater functional gains during rehabilitation than older individuals. •Younger individuals with tetraplegia (or in a mixed traumatic, nontraumatic sample) are more likely to make gains in neurological status during rehabilitation than older individuals.